Tenn. Comp. R. & Regs. 1200-08-15-.14 - DISASTER PREPAREDNESS

(1) Emergency Electrical Power.

(a) All residential hospices must have one or more on-site electrical generators, which are capable of providing emergency electrical power to at least all life sustaining equipment and life sustaining resources such as: ventilators; blood banks, biological refrigerators, safety switches for boilers, safety lighting for corridors and stairwells and other essential equipment.

(b) Connections shall be through a switch which shall automatically transfer the circuits to the emergency power source in case of power failure. It is recognized that some equipment may not sustain automatic transfer and provisions will have to be made to manually change these items from a non-emergency powered outlet to an emergency powered outlet or other power source. All emergency power transfer switches shall be labeled as such. Switches affecting heat, ventilation, and all systems shall be labeled.

(c) The emergency power system shall have a minimum of twenty four (24) hours of either propane, gasoline or diesel fuel. The quantity shall be based on its expected or known connected load consumption during power interruptions. In addition, the residential hospice shall have a written contract with an area fuel distributor which guarantees first priority service for re-fills during power interruptions.

(d) The emergency power system (generator) shall be inspected weekly and exercised and under actual load and operating temperature conditions for at least thirty (30) minutes, once each month including automatic and manual transfer of equipment. The generator shall be exercised by trained facility staff who are familiar with the systems operation. Instructions for the operation of the systems and the manual transfer of emergency power shall be maintained with the facility's disaster preparedness plan and shall be separately identified in the plan. Records shall be maintained for all weekly inspections and monthly tests and be kept on file for a minimum of three (3) years.

(2) Physical Facility and Community Emergency Plans.

(a) Physical Facility (Internal Situations).

1. Every residential hospice shall have a current internal emergency plan, or plans, that provides for fires, bomb threats, severe weather, utility service failures, plus any local high risk situations such as floods, earthquakes, toxic fumes and chemical spills. The plan should consider the probability of the types of disasters which might occur, both natural and "man-made".

2. The plan(s) must include provisions for the relocation of persons within the building and/or either partial or full building evacuation. Plans that provide for the relocation of patients and/or residents to other health care facilities must have written agreements for emergency transfers. The agreements may be mutual, i.e. providing for transfers either way.

3. Copies of the plan(s), either complete or outlines, including specific emergency telephone numbers related to that type of disaster, shall be available to all staff. A copy shall be readily available at all times in the telephone operator's position or at the security center. Provisions that have security implications may be omitted from the outline versions.

4. The plan must provide for additional staffing, medical supplies, blood and other resources which would probably be needed.

5. Each of the following disaster preparedness plan drills shall be conducted annually. Drills are for the purpose of educating staff, resource determination, testing personnel safety provisions and communications with other facilities and community agencies. Records of staff orientation, education programs and drills must be maintained for at least three (3) years.

(i) Fire Safety Procedures Plan shall include:

(I) Minor fires

(II) Major fires

(III) Fighting the fire

(IV) Evacuation procedures

(V) Staff functions by department and job assignment

(VI) Fire drill schedules (fire drills shall be held at least quarterly on each work shift)

(ii) External disaster procedures plan (for tornado, flood, earthquakes) shall include:

(I) Staff duties by department and job assignment

(II) Evacuation procedures

(iii) Bomb Threat Procedures Plan:

(I) Staff duties by department and job assignment

(II) Search team, searching the premises

6. The residential hospice shall develop and periodically review with all employees a pre-arranged plan for the orderly evacuation of all patients and/or residents in case of a fire, internal disaster or other emergency. The plan of evacuation shall be posted throughout the facility. Fire drills shall be held at least quarterly for each work shift for residential hospice personnel in each separate patient/resident-occupied residential hospice building. There shall be a written report documenting the evaluation of each drill and the action recommended or taken for any deficiencies found. Records which document and evaluate these drills must be maintained for at least three (3) years.

(b) Emergency Planning with Local Government

1. All residential hospices shall establish and maintain communications with the county Emergency Management Agency. This includes the provision of the information and procedures that are needed for the local comprehensive emergency plan. The facility shall cooperate, to the extent possible, in area disaster drills and local emergency situations.

2. Each residential hospice must rehearse both the Physical Facility and Community Emergency plan as required in these regulations, even if the local Emergency Management Agency is unable to participate.

3. A file of documents demonstrating communications and cooperation with the local agency must be maintained.

Notes

Tenn. Comp. R. & Regs. 1200-08-15-.14

Original rule filed August 18, 1995; effective November 1, 1995. Amendment filed February 9, 1998; effective April 25, 1998. Repeal and new rule filed April 27, 2000; effective July 11, 2000. Amendment filed November 22, 2005; effective February 5, 2006.

Authority: T.C.A. §§ 4-5-202, 4-5-204, 68-11-202, 68-11-204, 68-11-206, and 68-11-209.